A parent brings a 4-month-old infant to the clinic.
The infant has had a runny nose, a slight fever, and a cough for the last two days.
Which of the following findings should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/min.
Bilateral bronchial breath sounds.
Flaring of the nares.
The Correct Answer is D
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
D.
Choice A rationale
Initiation of peripheral IV access is a common procedure in the emergency department for patients who have experienced a fall. This allows for the administration of fluids and medications as needed.
Choice B rationale
An X-ray of the left shoulder and right knee would likely be ordered given the patient’s report of pain in his left shoulder after the fall. This would help to identify any fractures or other injuries.
Choice C rationale
A CT scan of the brain may not be necessary in this case, unless the patient was experiencing symptoms such as confusion, loss of consciousness, or other neurological signs following the fall.
Choice D rationale
Administration of pain medication would likely be initiated based on the patient’s report of pain.
Correct Answer is C
Explanation
Choice A rationale
While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice B rationale
While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice C rationale
Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.
Choice D rationale
While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.